• Habits, behaviors, lifestyles or conditions that increase the probability of disease occurrence

Example: medication, age, oral habits, genetics, culture, SES, etc...

1. determine treatment needed              (includes prevention)
2. caries is a preventable infectious disease
3. nonsurgical approaches to repair/reverse incipient lesions
4. minimally invasive procedures if detected early (less tooth structure lost)

• attempt to predict the future caries development BEFORE the clinical onset
• risk factor versus risk indicator

*you want to do do this every time you see a patient!

1. stopping caries before they start (ideal)
2. arrest & halt progression if it's an incipient lesion
3. treat current carries (overt/frank lesions) & stop further development

• you need to know how the bacteria originally populates the oral cavity
  • the main source is the primary caregiver through vertical transmission (close contacts)
  • example: pacifiers, bottles & spoons

*The ↑ the bacterial counts in the primary caregiver, the earlier the risk of bacterial colonization in the child

• visible plaque on the labial surfaces of maxillary incisors of young children is a serious sign of caries risk
• this should be the easiest place to clean
• ↑ ECC

What % of adolescents & adults

test positive for MS?

• 80%

What other factors (aside from # and

virulence of bacteria from primary caregiver) have an affect on transmission?

1. immunity
2. health
3. amount of transmission
4. pH of oral cavity
5. F present in water
6. home care

• we can use the information to classify them as a low, moderate or high risk patient

How can we use risk assessment information

for a person becoming a parent?

For a new parent? Or for the infant?

1. educate parents
2. teach them how to prevent vertical transmission
3. don't drop too much information on the new parent at one time or you will overwhelm them

*risk assessment is individualized and would look different for a senior citizen versus for a child - a child may have ortho while a senior takes medications and has different food choices

• Attempt to reduce the bacterial load in the parents mouth
  1. chlorhexidine rinse (0.12%)
     • 30 second rinse @ bedtime
     • bad after taste
     • don't rinse with water immediately after
  2. limit fermentable carbs
  3. xylitol (straight)
     • can not be metabolized by MS or LB
     • 5-6 grams/day delivered via gum
  4.  at home F at night once chlorhexidine is completed

1. social history: dental history could determine low/high risk
   • example: "tell me about your past visits"
2. medical history: medical conditions and medication could determine low/high risk
3. use of F: exposure to F as a child could determine low/high risk
   • example: "where did you grow up", "was there F in your water as a kid", "do you use F toothpase/rinse"
4. dietary habits: ↑ fermentable carbs and MS levels could determine low/high risk
5. biofilm control: home care could determine low/high risks
6. clinical/oral evaluation: pH, past restorations, exposed root surface & past cavities could determine low/high risk

1. ↑ cariogenic food intake
2. low saliva or loss of buffering capacity
3. plaque accumulation due to insufficient oral hygiene (home care)

*most often it's reversible and just a "local shift" in ↑ bacteria due to a harder to clean area

How can you gather information from somebody about a possible shift of bacteria in thier

mouth to harmful?

• ask questions
• plaque index with disclosing solution

• If there is no intervention - demineralization will continue and cavitation can occur
• Clinically visible (may not be seen on radiographs)
• If there is intervention - the cavitation can be remineralized 

1. groups/populations
2. individiual

1. elderly population
2. children in daycare environment
3. children in a low SES environment
4. nursing mothers
5. adolescents
6. pre-orthodontics
   • preventing demineralization
7.  post orthodontics
   • encouraging remineralization

*look at each group and customize treatment/interventions strategies

1. pit & fissure
2. proximal surfaces
3. cervical areas

• difficult to detect with accuracy
• diagnodent helpful
• enamelplasty (widening of the fissure)
• difficult to determine benefits of remineralization
• prevention techniques

*some people are just born with big pits, doesn't always = bad home care!

• radiographic detection
• surgical intervention if through the enamel into the DEJ
• if still in enamel, remineralization techniques
• prevention techniques (example: flossing)

• remineralization possible
• difficult to control and treat because root surface & dentin are soft
• pH is very important (6-6.7)
• F therapy is critical

• utilized to determine effective treatment & monitor progress
• chairside methods (example: determining levels of S. mutans in saliva)

*home care of the patient is an independent factor that could influence the outcome of bacterial collection

• a graphical picture illustrating in an interactive way the patient's risk for developing new dental caries in the future
• can be used in the clinic or education facilities
• can use the information for patient education to show them what factors influence the likelyhood of cavitation

1. facial expression
   • example: eye rolling & looking away
2. body language
   • crossed arms & sighing
3. misuse of words
   • "woops", blood, yuck

1. Listening
   • patients, boss, coworkers, fellow students
   • active listening
   • example: drive through →repeating conversation back to the patient
2. Observing & attending
   • acknowledgment, empathy, body language
   • letting the patient know you are attentive
   • example: eye contact, touching, nodding
3. Understanding behavioral styles
   • many ways to "sterotype" people
   • example: intervert vs. extervert

*Keep your communication to the level of your patient!

• The goal of effective communication is to build rapport (having your patients trust you)

1. let the patient know you care about their health
2. ask questions
3. have empathy

*customize your communication to your patient specifically

1. Avoid unnecessary encroachment on personal space of the patient
2. Cultural sensitivity
   • example: pointing at some people may be offensive
3. Culture of your work environment
   • example: decor, smell, pictures in the ops, friendliness of the staff
4. Time
   • respect everyones time (including the patients)
5. Understand verbal and nonverbal cues
   • example: crossing arms
6. Express an interest in what the patient/dr/coworker is discussing
   • example: nodding or repeating things
7. Look for emotional cues from the patient
   • example: body language - are they feeling pain or discomfort? how can you tell?
8. Respond with empathy
   • example: touching & showing sorrow
9. Demonstrate respect
   • example: looking into somebody eyes
10. Express emotional warmth
    • example: empathy
11. Be direct and genuine
12. Provide constructive feedback
13. Use "I" words when possible
    • example: "I feel"...

• use appropriate verbiage
• be specific about behaviors that can be changed
• be nonjudgmental
• consider the patient's needs & not yours
• give immediate feedback                     (offered through positive reeinforcement)

What is motivation?

• interaction between the environment, personal and behavioral factors
• a set of processes that determine individual choices
• readiness to act if motivated
• set of forces that cause people to behave in certain ways

• ambivalence keeps people from being motivated
  1. conflict with a person
  2. different things are valued differently by different people                         example: some people care about their teeth, some don't
  3. empathy
  4. assist the patient in understanding the discrepancy between thier behavior and thier goals
  5. avoid arguing
  6. don't judge or impose your views
  7. support the patient in their decision to succeed, not yours

• if we provide the knowledge, the patient will automatically change thier behavior           (not true, the patient has to want to change)
• information (education) is paramount - but- the patient must have the motivation to change the behavior
• what shapes our behavior is multifactorial

1. external motivation
   • little control
   • believe in fate
   • require more supervision/direction
   • need outside reinforcement
2. internal motivation
   • self responsible
   • control over own health
   • motivated to long-term health changes

1. deficiency needs - fundamental to "comfort"
   • physiological
   • security (safety)
   • sense of elonging (social)
   • self-esteem
2. growth needs-self-actualization
   • things that you want, not necessarily what we need

*all behanior is motivated by deficiency needs.  you must meet your needs before you can move to your wants

1. previous bad experience
2. pain (physical or emotional)
3. age                                                 example: "too old to care"
4. educational                                      example: lack of education or inability to educate
5. acceptance by peers
6. poor self-image
7. low SES

• change requires challenging a person's value system - that's not always an easy process! example: educating a mom about how to care for her children - you may be insulting her parenting skills as she is just doing things the way her mom did when she grew up

Different modles

1. Health Belief Model
2. Theory of Reasoned Action
3. Transtheoretical Model
4. Social Cognitive Theory

1. Perceived susceptibility
   • person's perception of risk          example: am I susceptible?
2. Perceived severity
   • person's perception of the severity example: how serious are the consequences?
3. Perceived benefits
   • will the interventions reduce or eliminate my susceptibility?

*example:

how would you discuss 2 new carious lesions to a patient and the need for a F application?

- susceptibility - "you have 2, you are at risk"

- severity - the 2 need to be filled now

- benefits - take care of these and save $ on a

                crown later & a F application will help

                to stop the further demineralization

• Behavior intent is the most important
  • attitude toward the expected outcome of the behavior + subjective norms (the influence other people have on a person's attitude or behavior) = major predictor of intentions

*example:

getting a teen ager to brush his teeth

utilize expected outcome (fresher breath)

+

subjective norm (girlfriend thinks breath stinks)

=

intention (brush more often to freshen breath and

              make girlfriend happy)

Stages of change:

1. Precontemplation
   • ignorant of positive consequences of changing behavior
2. Contemplation
   • cognizant of positive consequences of changing behavior and will do so in the future
3. Preparation
   • planning on making the change
4. Action
   • actually have incorporated the change but less than a 6 month period
5. Maintenance
   • have incorporated the change for 6 months+
6. Relapse

• behavior & behavior change is affected by personal & environmental factors
• modeling of behavior is an effective way to change behavior (example: parents)
  •  
    1. set desirable outcomes
    2. identify the variables
    3. design interventions to modify the variables

How do we teach our patients?

1. ladder of learning
2. education (blooms taxonomy of education objectives)

Ladder of Learning

1. unawareness
2. awareness
3. self-interest
4. involvement
5. action
6. habit

1. knowledge
2. comprehension
3. application
4. analysis
5. synthesis
6. evaluation

*in dentistry, individualized instruction is better than mass instruction

your patient & learning

• initial instruction should be given before clinical tx because your patient is more inclinded to care vs. at the end of tx
• don't talk to your patient when they are in a compromising position unless it is effective example: you want to be face-to-face unless you can show them with a hand mirror what you are doing in thier mouth
• talk, show, do                                  example: have the patient demo for you
• constructive feedback
• KISS (keep it simple stupid)

• must have good communication skills in order to establish rapport
• good patient rapport leads to a level of trust
• patients must have a basic level of trust in thier health care providers
• motivation and behavioral changes can grow from this point
• people are motivated by different things and in different ways (know thier hot buttons)
• there are numerous barriers to motivation
• will need to overcome some or all barriers in order to motivate patients towards behavior change
• according to maslow, no behavior change is possible until certain basic needs are met
• different models on how and why motivation and behavior change will or will not take place